Failing Grades for Doing the Right Thing

The following post is by Dr. Lauren Demosthenes, Associate Professor of Obstetrics & Gynecology at the University of South Carolina, Greenville

Health care charges and costs – it’s still a topic that seems uncomfortable for physicians to talk about. I started practice 28 years ago and every month, I have received what seems like a report card to me – each physician is listed with the number of patients seen – along with charges generated. There is no column for following guidelines or saving patients money by choosing a more conservative and less costly treatment. I’m paid based on charges – and only based on charges. It has never seemed right to me, but that has been the culture.

Now 28 years later, I am hoping for change. We have learned that many items, tests, and services in healthcare are unnecessary, and may actually lead to harm and more costs as follow-up testing is performed. More is not always better. It’s hard to change these habits because physicians are financially rewarded for doing more tests, and patients sometimes think that more testing is good. After all, “better safe than sorry” . Let’s look at an example from my world as an obgyn.

Mrs. Smith is a 40 year old woman who has always had her annual pap smears –With the change in pap smear guidelines, she does not need a pap smear this year. Mrs. Smith comes in for her annual well woman visit and she expects a pap smear – she has always thought that screening for cervical cancer was very important and she is a little worried over this new recommendation and expresses this concern to her physician.

So a pap smear is performed. This takes less time than counseling her about why the pap smear guidelines have changed. And it makes the patient happy because it makes her feel safe.

It returns showing mild dysplasia, so she returns to the office for another appointment which includes a colposcopy and biopsy. Mild dysplasia is confirmed on the biopsy and the patient is told that this does not need treatment but that she should have another pap smear in 6 months. She is a little anxious, but relieved that this abnormality was “caught in time”.

So the patient had some anxiety, expense, discomfort and an a couple of extra procedures over this. But she is happy that her Dr. didn’t follow the guidelines – after all, he found something and now he will follow it closely. But….The pap smear did not need to be done. The physician generated a charge and a collection. And…….The pap smear did not need to be done…………..

As a physician, what do we have to believe in? This is just my opinion, but I think that physicians have to believe in educating their patients about why certain tests don’t need to be done – I also think we have an obligation to society as a whole to be good stewards of health care dollars. It does take more work to teach patients about why a test may not need to be performed– in fact it takes longer to explain this than to just do the test. And in my current system, the grade on my “report card” is lower for doing the right thing rather than the more expensive thing.

The U.S. system cannot continue as it is and physicans and patients together must understand that more is not always better. Choosing Wisely is an initiative by the American Board of Internal Medicine – an initiative with the goal of engaging physicians, patients and other health care stakeholders to talk about medical tests and procedures that may be unnecessary and do not benefit patients.

The American College of ObGyn is a new partner with the ABIM and will announce their 5 Choosing Wisely items in February. I don’t know what will be on the list, but I’m hoping that education about pap smears is at the top.

m4s0n501

2 Comments

Jay WarnerFebruary 21, 2013

I am not in the medical profession but I always thought guidelines were guidelines and not absolutes. Don’t doctors have the discretion to do what they feel is best depending on the patient they are seeing? If she didn’t have the PAP done, would the mild dyplasia have become worse by the time she was allowed to have another PAP per the guidelines? I’m genuinely interested in how much leeway the doctors have to practice their own profession given the confines of the health care industry and the focus on the dollar cost rather than patient safety.

Most mild dysplasias resolve spontaneously. No treatment needed. Progression from mild to cancer is very slow so progression would be discovered within the recommended interval.
I agree that guidelines are not absolutes. We deviate if in the best interest of the patient. My goal is not to decrease quality — it is to decrease unnecessary tests, products and services that do not add to quality — but do add to cost. And may, in fact, lead to other tests and procedures that actually increase risk for the patient.
Thank you for your thoughtful response to the blogpost.